The postmodernist critique of science consists of two interrelated arguments, epistemological and ideological. Both are based on subjectivity. First, because of the subjectivity of the human object, anthropology, according to the epistemological argument cannot be a science; and in any event the subjectivity of the human subject precludes the possibility of science discovering objective truth. Second, since objectivity is an illusion, science according to the ideological argument, subverts oppressed groups, females, ethnics, third-world peoples.

Well, it’s not really postmodernism per se that I detest. In the humanities, I don’t mind it so much, although reading postmodernist texts in college did make my head hurt. I suppose that in the humanities postmodernism provides a sometimes useful methodology for providing insights into interpretation of a wide variety of subjects in literature and the arts, although much of the time it seems to exist mainly to try to make texts mean exactly the opposite of what the words on the page say. Relying as it does on deconstruction, which is primarily a form of literary analysis, postmodern analysis is built on questioning the assumptions underlying any text, “deconstructing” its meaning. The problem is, it’s rare that a postmodernist critique of anything doesn’t consist of some of the densest, most impenetrable verbiage in existence.

Since I don’t claim to be a philosopher, and I haven’t studied postmodernism since college, I don’t intend to embarrass myself by trying to do a detailed–ahem–deconstruction of what postmodernism is. Many are the trees that have been killed to write books trying to explain what postmodernism is and how to apply it to various subjects. I do know, however, that postmodern philosphy is skeptical–even nihilistic–when it comes to the values of what is considered “modernity.” Unfortunately, to some, science is one of these modern values that is viewed with extreme skepticism, even to the point of representing the very essence of science as nothing more than one narrative among many. True, Spiro was writing primarily about anthropological science, but medicine is a “soft” enough science to be just as easily attacked in such a manner, and postmodernists don’t limit themselves to the “soft” sciences, anyway. Even worse, these sorts of arguments often claim that science (or, in this case, evidence-based medicine) is nothing more than a sort of hegemony of the power structure being imposed upon the very definition of “data” or “reality,” the implication that it’s us white males whose hegemony is being served (and whose hegemony, presumably, must be resisted) doing the imposing, as if there are no inherent characteristics in science that make it a more reliable means of assessing reality as it exists than, for example, personal anecdote and “experience.”

No wonder woo-meisters and those who hate the very concept of evidence-based medicine (as opposed to the deficiencies in how EBMranks evidence, which in fact were the reason why this blog is called Science-Based Medicine and not Evidence-based Medcine) love postmodernism so much. It’s the perfect tool for them to appeal to other ways of knowing and try to make it seem as though scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” (or qi) for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine.

Perhaps the best quick explanation of how postmodernism is used to attack science comes from Rob Helpy-Chalk:

Knowledge was always in some way relativized to culture, so that it was possible to talk about many “equally valid ways of knowing” of which enlightenment science was only one. For instance, contemporary biologists say that the cassowary (an ostrich-like creature) is a bird, albeit one that cannot fly. The Karam people of New Guinea, who live alongside the cassowary, say that the cassowary does not belong in the same category as the birds (which they call yakt) but bats do belong to that category. So who’s to say that the biologists are right and the Karam are wrong? Knowledge is all relative.

Claims to knowledge were also always in some way “constructed” or “socially constructed” in the postmodernist movements. This meant that they had less to do with grasping the way the world actually works and more to do with creating social structures that advanced the interests of the people who claimed to have knowledge. The science of thermodynamics was not really a description of the properties of heat. It was about convincing people to buy steam engines and arranging society so that they would be happy when they bought one.

Thus, one of the key tenets of some strains postmodernism is that knowledge is relative and “socially constructed,” usually for the purpose of reinforcing the existing power structure or furthering the interests of the “elite” who have the knowledge. It is therefore not surprising that critics of evidence-based and science-based medicine would find postmodernism to be a very attractive philosophical mantle in which to wrap their objections to the science that does not support their favored understanding of how disease works or what treatments are effective. After all, if all knowledge is relative, then why shouldn’t their way of knowing be just as valid as that of science, given that in the postmodernist view as used (or, as many philosophers would characterize it, abused) by “postmodernist” critics, science is just “another narrative.”Evidence-based medicine as “microfascism”

Perhaps the most hilariously over-the-top criticism of medicine as a Tool of the Man designed to suppress and control Brave Mavericks (not John McCain) was published two years ago in the form of an article by Dave Holmes, RN, PhD, Stuart J. Murray, PhD, Amélie Perron, RN, and Geneviève Rail, PhD, entitled Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. The article was published, ironically enough, in the International Journal of Evidence-Based Health Care. I choose it for two reasons. First, it is so over-the-top that it brings the postmodernist attack on scientific medicine into sharp relief. Second, when you come right down to it, the sorts of arguments made by Holmes et al are the same as many arguments made by aficionados of complementary and alternative medicine (CAM).

Background: Drawing on the work of the late French philosophers Deleuze and Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena.

Objective: The philosophical work of Deleuze and Guattari proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.

Conclusion: The Cochrane Group, among others, has created a hierarchy that has been endorsed by many academic institutions, and that serves to (re)produce the exclusion of certain forms of research. Because ‘regimes of truth’ such as the evidence-based movement currently enjoy a privileged status, scholars have not only a scientific duty, but also an ethical obligation to deconstruct these regimes of power.

I don’t know about you, but when it comes to my healthcare, I actually want my physicians to be “outrageously exclusionary”–exclusionary to quackery, that is. I also had no idea that the Cochrane Collaboration was so amazingly powerful. Whatever reasonable criticisms of the whole EBM paradigm may be, they don’t include labeling the Cochrane collaboration as fascistic. “Micro”-fascist that I apparently am for advocating science and evidence-based medicine, let’s see if I can place my “micro”-jackboot right on the throat of this sort of argument, apply sufficient pressure to make it gasp for air, and then apply my “micro”-truncheon liberally to its face, all the while resenting that the authors apparently didn’t consider EBM enough of a threat to label it real fascism. (I’ll leave it to the postmodernist authors of the paper to figure out whether I’m being facetiously metaphorical or not.)

Basically, this entire article is a huge appeal to other ways of knowing, coupled with massive straw men arguments, with a few other logical fallacies sprinkled in liberally for seasoning. The article begins:

We can already hear the objections. The term fascism represents an emotionally charged concept in both the political and religious arenas; it is the ugliest expression of life in the 20th century. Although it is associated with specific political systems, this fascism of the masses, as was practised by Hitler and Mussolini, has today been replaced by a system of microfascisms – polymorphous intolerances that are revealed in more subtle ways. Consequently, although the majority of the current manifestations of fascism are less brutal, they are nevertheless more pernicious.

You can almost hear the authors rubbing their hands together and cackling at being so…contrary, so…naughty, so…against the old stodgy scientists who think that we can actually know or measure reality with something close to objectivity. In other words, they’re just throwing in the comparison because it’s inflammatory. It’s tempting to appeal to Godwin’s law and just be done with it, but I think you’ll soon see why this attitude needs to be examined. They then state their objective:

Drawing in part on the work of the late French philosophers Deleuze and Guattari the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena.

Yes, I suppose that one would find EBM to be “outrageously exclusionary” if one is a quack. But let’s get to the meat (or what passes for meat in this article). First, here’s the straw man that the authors harp on over and over and over:

As a global term, EBHS (evidence-based health sciences) reflects clinical practice based on scientific inquiry. The premise is that if healthcare professionals perform an action, there should be evidence that the action will produce the desired outcomes. These outcomes are desirable because they are believed to be beneficial to patients. Evidence-based practice derives from the work of Archie Cochrane, who argued for randomised controlled trials (RCTs being the highest level of evidences) as a means of ensuring healthcare cost containment, among other reasons. In 1993, the Cochrane Collaboration, serving as an international research review board, was founded to provide clinicians with a resource aimed at increasing clinician-patient interaction time by facilitating clinicians’ access to valid research. The Cochrane database was established to provide this resource, and it comprises a collection of articles that have been selected according to specific criteria. For example, one of the requirements of the Cochrane database is that acceptable research must be based on the RCT design; all other research, which constitutes 98% of the literature, is deemed scientifically imperfect.

Not exactly. While it is true that the Cochrane Collaboration considers randomized clinical trials (preferably double-blinded) to be the a very highest form of evidence; it does not follow that all other research is “scientifically imperfect,” simply for the reason that RCTs are not considered “perfect.” No science is, nor does the Cochrane Collaboration insist on or use only RCTs in formulating its literature reviews. True, there are some “true believers” who do push rigid EBM as a panacea, but they are definitely in the minority and tend to be viewed skeptically among most other EBM advocates. Moreover, as this blog shows, if anything EBM undervalues certain forms of evidence, specifically basic science, thus making EBM problematic when studying non-science-based health care modalities. Nonetheless, other than its devaluing of basic science, EBM gets it pretty close to right when it comes to ranking forms of evidence derived from clinical trials.

We believe that health sciences ought to promote pluralism – the acceptance of multiple points of view. However, EBHS does not allow pluralism, unless that pluralism is engineered by the Cochrane hierarchy itself. Such a hegemony makes inevitable the further ‘segmentation’ of knowledge (i.e. disallowing multiple epistemologies), and further marginalise many forms of knowing/knowledge.

Ah, yes. “Pluralism.” Whatever that means when it comes to scientific evidence. Does that mean that unscientific bunk like homeopathy should be considered as deserving of equal consideration as EBM, all in the name of “pluralism”? Personally, when it comes to pseudoscientific crap like this, EBM should be “outrageously exclusionary.” However, even more than the “exclusionary” nature of EBM, what really seems really to bother the authors is the language of EBM and science, presumably because of its emphasis on evidence, reason, and fact:

We believe that EBM, which saturates health sciences discourses, constitutes an ossified language that maps the landscape of the professional disciplines as a whole. Accordingly, we believe that a postmodernist critique of this prevailing mode of thinking is indispensable. Those who are wedded to the idea of ‘evidence’ in the health sciences maintain what is essentially a Newtonian, mechanistic world view: they tend to believe that reality is objective, which is to say that it exists, ‘out there’, absolutely independent of the human observer, and of the observer’s intentions and observations. They fondly point to ‘facts’, while they are forced to dismiss ‘values’ as somehow unscientific. For them, this reality (an ensemble of facts) corresponds to an objectively real and mechanical world. But this form of empiricism, we would argue, fetishises the object at the expense of the human subject, for whom this world has a vital significance and meaning in the first place. An evidence-based, empirical world view is dangerously reductive insofar as it negates the personal and interpersonal significance and meaning of a world that is first and foremost a relational world, and not a fixed set of objects, partes extra partes.

This is simply the age-old complaint that modern medicine doesn’t sufficiently value the humanity of the patient, that it’s cold and uncaring, interested only in reason and science, a complaint that has been around ever since we first started to base medical practice on science rather than folklore. I applaud these postmodernist authors, though, for showing admirable restraint in refraining from doing what I expected and mentioning Dr. Josef Mengele as a natural consequence of the fascistic scientific world view in which an objective reality is acknowledged. Besides, the universe doesn’t give a damn what we humans believe about it. Gravity will still cause you to tumble to the ground, whether you believe in it or not. Cancer cells don’t pay attention to the observer’s intentions and observations. Neither do microbes. As science has shown us, they do, however, pay attention to chemotherapeutics and antibiotics.

Indeed, the entire reason for the evolution of medicine from empirical, experience-based treatments to EBM comes from the very fact that the old ways were prone to a number of biases. The placebo effect guarantees that almost any intervention will make some proportion of patients with a given condition feel better, at least transiently. That’s the main reason for double-blinding and randomization when possible. Many diseases are either self-limited or their course waxes and wanes. If a patient tries something (or a doctor tries something on a patient) right before the disease symptoms wane, he or she will likely falsely attribute the clinical improvement to whatever was done right before, even though the intervention may or may not have had anything to do with the patient’s improvement! Confirmation bias means that, if you expect a treatment to work, your tendency, unintentional but real, will be to remember bits of evidence that fit with what you expect and to disregard or forget those that contradict what you expect. Because human observation is so fallable and so easily able to misrepresent objective reality is exactly what the scientific method corrects for. There are many other such pitfalls, thanks to human cognitive quirks and our brains’ hardwiring to attribute cause to correlation. It has been through experience, actually, that we have learned that the scientific method is the best method we currently have to correct for what would lead us astray.

I’ll give Holmes and his crew of postmodernists credit for one thing. They don’t give up. Having been thoroughly slapped down by a large number of scientists for referring to EBM (and, by extension, science itself) as “microfascism,” they turn their postmodernist eye to evidence itself. In the very latest issue of the Journal of Research in Nursing, they have published a followup to their infamous “microfascist” paper entitled On the constitution and status of ‘evidence’ in the health sciences, this time first-authored by Stuart J. Murray. This article is almost as good (bad) as whole “microfascism” rant. (The only reason it’s not as good or better is the lack of a term as cringe-worthy as “microfascism.”) Basically, it’s the same tired old refrain that science is nothing more than the existing power structure exerting its will to enforce “conformity.” Because the article is not available to a lot of my readers, I feel obligated to quote fairly liberally from it to give you a flavor of just how ridiculous it is. The authors’ intent is made plain right from the first sentence:

What constitutes ‘evidence’ in the health sciences? Without too much hesitation, we might say that scientific evidence is worthwhile if it can be repeated, independently verified and measured according to standards upon which we can all agree. We might call this the ‘common sense’ view and commonsensically believe that these conditions hold as true not just in the sciences but also in our daily dealings in the world. We might even say that nothing could be more straightforward, that evidence in this context is obvious or ‘self-evident’ and that in the end, ‘seeing is believing’. In this paper, we suggest that this cheerful proverb stands as a kind of emblem for the dangerously naïve commonsense view on truth that has spread throughout our culture. We argue that this view betrays an almost unshakeable faith in the human capacity for unbiased or objective observation and analysis. Ultimately, this means that science becomes supplanted by ideology, and scientific inquiry becomes a ‘methodological fundamentalism’ (House, 2006).

This is of course, nothing but the old “fundamentalism” charge leveled against those of us who actually think that scientific rigor is important in determining what treatments work and what treatments do not. It’s the same charge routinely leveled against evolutionary biologists by creationists, be they “intelligent design” creationists or the old hard core young Earth creationists. It’s the same charge leveled by pseudoscientists of all stripes against scientists who correctly tell them they are pseudoscientists: That scientists are rigid, close-minded, unable to think “outside the box,” interested only in supporting existing understanding. To them, as I mentioned before, science is nothing more than a Tool of the Man to enforce cultural hegemony and, more importantly, to keep the Brave Mavericks down. In fact, the entire premise of this article is based on a huge straw man, as is shown here:

This paper discusses the constitution and status of ‘evidence’ in light of the almost evangelical rise of evidence-based health sciences (EBHS), including nursing. One salient example is the Cochrane Library, which provides EBHS acolytes with a database of ‘systematic reviews’ that has been faithfully constructed according to the evidencebased movement (EBM) directives. Thus, within the Cochrane Library’s hierarchy of allowable ‘evidence’, the randomised controlled trial (RCT) is taken as the ‘gold standard’, and proponents will scoff at any criticism because the RCT can be repeated, independently verified and measured according to standards upon which we can all (presumably) agree. It is not rocket science, or so they will say. But here with the seemingly innocent exaltation of the RCT, we find an explicitly hierarchical ranking that denigrates the evidentiary value of clinical experience; and similarly, qualitative research based, among other things, on participants’ narratives is ‘systematically’ ranked lower in value as ‘evidence.’

Thus, the most faithful proponents of EBHS must adopt a position in which “seeing is believing”–where evidence is presumed to be visual, immediate and incontestable. It is as if the evidence itself spoke the truth, and EBHS finally realised the dream of a pure science, a science free from the inherent messiness of human language, of human interpretation, of human values or, indeed, of anything recognisably human because the body that EBHS treats is the ‘average body’ generated by the RCT, without any experimental body. Nevertheless, within the culture of the health sciences, EBHS now circulates as a kind of fundamental truth, and it can do so because EBHS has come to control the terms by which evidence appears. The EBM constitutes a vast matrix of influence from funding bodies and academic institutions to nursing best-practice guidelines (BPGs) and multiple-related postulates that inform day-to-day heath care practices. In other words, for EBHS, ‘seeing is believing’ because EBHS carefully limits what can be seen in the first place. EBHS limits not only what can appear within our visual field but also how it will appear and how that evidence will be framed. EBHS appeals to a culture that is taught to embrace simple directives and to be suspicious of intellectual critique.

A more massive strawman I have a very hard time indeed imagining. Could someone tell me where in the Cochrane literature (or any EBM literature, for that matter–or any science literature, come to think of it) does it say that evidence must be “visual, immediate, and incontestable”? What a load of rubbish! If evidence were that obvious, then EBM wouldn’t even be necessary. Certainly that tool of EBM, the meta-analysis, would not be necessary because the very reason to perform a meta-analysis is to try to develop a consensus when there are multiple trials that do not all agree. In fact, EBM can be viewed as a means of trying to make sense of clinical data supporting various treatments, even when the data are not clear or are conflicting. “Seeing is believing?” Ha! If only EBM were that easy! Actually, if EBM were that easy, anyone could do it, while science itself should, in ideal circumstances, guide the way.

Murray and his crew then go on to claim that “seeing is not always believing,” taking arguments about the social sciences and invoking, of all things, the Rodney King trial and the videotape evidence used, concluding:

Our point in referring to what many saw as a manifest injustice is to call attention to our ways of seeing and the often hidden politics of the evidence to hand. In the King case, many of us would draw a very different conclusion from the visual ‘evidence’, even though it is exactly the same piece of evidence: it can be repeatedly screened, its accuracy can be independently verified and it can be measured according to standards upon which we can all (presumably) agree. Although the evidence seems to present a truth that is pure and simple, as Oscar Wilde once quipped, the truth is rarely pure and never simple. The evidence cannot simply speak for itself because the meaning of that evidence is of another order altogether. Thus, we must worry about the ways in which evidence is manipulated and contextualised under the aegis of efficiency, in the name of political expediency or in the name of scientific progress, and sometimes all three at once, as in the famous case of the Tuskegee Syphilis Study, to offer one tragic example.

A rather amazing line of reasoning, don’t you think? Because a jury interpreted a videotape in a way that didn’t make sense to most people, Murray seems to be arguing, that means that EBM–even science itself–is wrong, a false, politicized concept! Truly, you can’t make stuff like this up. At least, no one with a scientific outlook can, except perhaps as parody. Never mind that the jury of the Rodney King trial were not scientists, and it wasn’t the scientific method being applied. Indeed, one reason the scientific method exists is to serve as a check against the very sort of problems in human perception that allow verdicts like that of the Rodney King trial to occur. In fact, I’m surprised they didn’t bring up the O. J. Simpson verdict as well. And, of course, EBM is just like the Tuskegee Syphilis Study, if you’re to believe this. Never mind that in addition to being incredibly unethical the Tuskegee Syphilis Study was actually pretty dubious science given that much was already known about the progress of untreated syphilis at the time it was done, making it completely unnecessary. This entire argument is nothing more than taking a germ of a reasonable criticism of EBM and going right off the deep end with it:

Our critical perspective develops some of the five shortcomings of the EBM succinctly described by Cohen, et al. (2004), namely, that EBHS [1] relies too heavily on empiricism, [2] relies on too narrow a definition of evidence, [3] ironically, lacks any evidence of its own efficacy, [4] is of limited use for individual patients and [5] threatens the autonomy of the clinician or patient relationship. In addition, however, our work has attempted to politicise the ways of seeing that have become common in the health sciences as a result of the EBM agenda (Holmes, et al., 2008; Holmes, et al., 2006a, Holmes, et al., 2006b; Murray, et al., 2007). In other words, we have sought to examine, to bring to light, the unexamined postulates that underwrite the EBM. From this critical perspective regarding what is now the dominant episteme, we claimed that the EBM was politically dangerous (Holmes, et al., 2006a). Relying on the French philosophers Deleuze and Guattari (1987), we argued polemically that the EBM is akin to a totalitarian political structure and, consequently, that its way-of-seeing is informed by a politically dangerous ideology. In a nutshell, we noted that the EBM wholeheartedly adopts corporate models of efficiency and accountability, right down to a corporate lexicon; EBM relies reductively on quantitative evidence in which RCTs are fetishised; EBM denigrates other forms of knowledge, including clinician experience and patient testimony; finally, EBM evacuates the social and ethical responsibilities that ought to distinguish health care professions, such as nursing.

Oddly enough, I’d tend to agree with some of these. First, EBM does tend to rely too heavily on empiricism, but not in the way that is meant in the passage above. Our criticism of EBM is that EBM relies on empiricism while devaluing previous understanding of basic science that can guide us regarding the plausibility of proposed treatments. In other words, to EBM, it matters very little that, for example, homeopathy goes completely against the laws of chemistry and physics as we currently understand them, an understanding based on hundreds of years of research and understanding. All that really matters in EBM is what the clinical trials, especially the RCTs, say. While RCTs are the most rigorous way to test most medical hypotheses, that is only true if the hypotheses being tested have some measure of plasuibility based on basic and clinical science. Indeed, that is the very reason that EBM is so easily coopted by CAM advocates. RCTs testing hypotheses with low prior probability based on science inevitably generate false positive tests, the lower the prior probability the more likely the false positive. The answer to that problem is not to widen the definition of evidence; it is to narrow it further by explicitly taking into account basic science and prior probability in deciding which RCTs make sense to carry out. Prioritization with regards to whether an RCT should be done and in what order hypotheses should be tested by RCTs should be based on scientifically-determined estimated prior probability, which comes from cell culture, animal studies, and preliminary observations in humans. In other words, part of the answer is to become, in the terms of the “microfascism” article, even more “outrageously exclusive” in the sort of evidence we value as practitioners of science-based medicine–definitely not the kind of “solution” the authors would approve of. To us it’s about the science and using science to develop the best patient care. To postmodernist critic it’s not about evidence; it’s about resisting The Man, science be damned.

In fact, I suspect they’d consider Science-Based Medicine even more than “microfascism,” requiring “microresistance,” if this passage is any indication:

In short, we must find ways to combat the procrustean policies that have hijacked many modes of scientific inquiry and have led instead to a tangled web of ideological apparatuses, including Big Pharma; innumerable government lobbies; professional healthcare associations, such as the Registered Nurses’ Association of Ontario (Canada) and its compulsive endorsement of ‘best-practice guidelines'; academia and its research sponsors; the convergence of research and business with multiple stakeholders, both public and private; paradigms rewarding the bioentrepreneurship of biotech companies; service industries from the human genome sciences to multinational agribusiness complexes; corporate models from the ground up, including accountability practices and the obsession with quantification; the legal-juridical complex; and the insurance industry (Murray, et al., 2007). This list is by no means exhaustive, but it indicates that the challenges are legion. Nothing less than a multitude of micro-resistances is called for in each of these domains. In the face of a strategic fundamentalism that closes off debate, we must be mindful to resist in such a way that we open up critical debate and question those mechanisms that work to seduce us into complacency. In short, the health care sciences ought to work to foster an ethic of patient care that resists technocracy, that is, an ethic that will be respectful of and responsible for patient diversity for the good life (Murray, 2007).

In other words, like all good “microfascism” apparently EBM requires absolute “conformity” and enforces it by ruthless means. This is such utter nonsense on so many levels that it’s as breathtaking in its hyperbole as the original “microfascism” article while at the same time being yawn-inducing in its utter tedium. Yes, yes, we know. That nasty science and that nasty EBM construct restrict your freedom to consider any source of evidence you want, no matter how dubious. All this entire attack is is the “health freedom” movement dressed up in incomprehensible “diversity”-promoting postmodernist jargon to an even more laughable extreme than their previous articles.

Running as a thread throughout the entire article, I could also discern the “science was wrong before” argument so beloved of cranks of all stripes, along with a lot of other logical fallacies. Once again, what matters more than anything else are the political and social implications, because EBM must obviously controlled by all the things the they hate, the insurance industry, “bioentrepreneurship” and big pharma, the veritable Roots of All Evil and Threats to Diversity. To achieve their aim of destroying EBM (with a minor concession that in their ideal world there would “still be a role” for RCTs, although their clear implication is that that role will be small), the whole argument boils down to a predictable appeal to other ways of knowing, in the form of advocating “resisting technocracy” and, above all else, promoting “diversity” (whatever that means). In reality, “diversity” appears to mean nothing more than the freedom of practitioners to believe or do whatever they want, science and evidence be damned–because, as people like Murray et al tell us, “evidence” is hopelessly corrupted by the power structure, whatever that means. Science is therefore nothing more than just one other way of knowing, with no inherent superiority to any other way of knowing how nature works or, on a practical level, what treatments work the best. Although Murray et al don’t come right out and say it, the implication of their argument is that if a quack believes that liver flukes cause cancer and that zapping the flukes with a cheap electrical device will cure all cancer, who is science or that nasty EBM to say that that’s not true? In any case, two years later, I still stand in awe of the amount of sheer antiscientific nonsense concentrated into such a brief little paper, and today I stand even more in awe that Murry, Holmes, and Rail have matched it.

“A more fluid concept of evidence”

You may laugh at the shenanigans embodied in articles like the two from which I have just liberally quoted, and indeed they are laughable in a great many ways, with their ludicrously dense, overblown, jargon-laden, pretentious rhetoric. But underneath all that jargon lie arguments very similar to the ones being used by advocates of unscientific medical practices and, yes, outright quackery, many of whom are opposed to science-based medicine in practice, although they will never admit it. For example, let’s consider the case of David L. Katz, MD, MPH, FACPM, of FACP, is founder and director of the Integrative Medicine Center (IMC) at Griffin Hospital in Derby, Connecticut, who is also an Associate Professor, Adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine. My co-blogger Dr. Kimball Atwood IV certainly has. Here’s the statement that Dr. Katz has become infamous for:

I think we have to look beyond the results of RCTs in order to address patient needs today, and to do that I’ve arrived at the concept of a more fluid form of evidence than many of us have imbibed from our medical educations…[Referring to a patient anecdote, Dr. Katz went on.] Now, we don’t want you on narcotics anymore than you want to be on narcotics. We initicated a course of acupuncture and over the next two to three months weaned him off narcotics. He was pain-free on acupuncture and subsequently transitioned into homeopathy. Now, I don’t care to get into a discussion of how or even whether homeopathy even works, but this guy had tried everything.

[…]

And the anecdotal evidence that homeopathy might be effective was brought up by the naturopaths. We tried it. It worked.

Of course, Dr. Katz neglects to describe exactly how he knew it “worked,” namely anecdotal evidence which, as we have seen many times in this blog, is incredibly prone to misinterpretation and confusing correlation with causation, thanks to a number of cognitive quirks we humans all share. Indeed, science itself, not just science-based medicine is designed to minimize the effects of these quirks. In response to criticism, Dr. Katz went even further:

The view I expressed, and that guides our practice, is that human need goes on long after the results of randomized clinical trials start to run thin. I do not think doctor and patient should part company there. I believe that responsible use of the science we have should not preclude responsiveness to the needs of patients that fail to respond as textbooks say they should to that all-too-limited science. I believe, in other words, that patient need, not trial results, should be the ultimate master medical care must serve.

I learned devotion to evidence-based practice from my teachers and professional colleagues; I was pushed toward integrative medicine by the needs of my patients.

See what I mean? Just like the postmodernist, Dr. Katz views science and EBM as nothing more than just another “narrative” that he can abandon when he sees fit or, as he puts it, when he perceives patient need to drive him to do so. Like postmodernists, he also views words as being malleable with meanings that can be “deconstructed” (in practice, changed) at will. Indeed, as Dr. Atwood correctly points out, these are subtle distortions of language that are very powerful and incredibly useful for CAM advocates. RCTs, “what we know,” and science are all conflated as though they mean the same thing, leading to a false dichotomy in which the only choice when the edges of what RCTs tell us are reached is to rely on anecdotes, testimonials, and other forms of unreliable and subjective “evidence” in order to justify choosing unscientific treatment modalities, even abject pseudoscience like homeopathy. Indeed, Dr. Atwood, as usual, put it well when he wrote:

It also follows that in the much larger realm of practices outside “that all-too-limited science,” there is no basis for distinguishing one from another. Since science has nothing to say about them, all are equally promising. All are thus fair game for the practitioner “pushed toward integrative medicine by the needs of [his] patients.”

Postmodernist, indeed. When you come right down to it,in practice there is no real difference between the postmodernist critique that EBM or scientific medicine represents nothing more than one method or “narrative” among many, all of which are equally valid, depending upon your point of view, and Dr. Katz’s apparent view that scientific medicine is simply another tool in his armamentarium, to be abandoned when he sees fit, all in the “name of the patient,” of course. Katz’s excuses have their origin in the very same sorts of fallacies that postmodernism leads to when applied to science or the scientific method, and, although it doesn’t sound as obviously ridiculous as the postmodernist articles I quoted, it is.

Similarly, the postmodernist criticism of EBM as nothing more than a “procrustean” methodology that ruthlessly enforces “conformity” and crushes the autonomy of the individual practitioner echoes the laments of CAM advocates who do not like scientific medicine because it fails to support the brand of woo they like. Indeed, all manner of advocates of antiscience in medicine invoke the same refrain: homeopaths, reiki practioners, “distance healers,” and many others. And let’s not forget HIV/AIDS denialists, who insist that the “dogma” that HIV causes AIDS is not based on science but rather ideology–and, of course, a big pharma conspiracy to make tons of money selling expensive antiretroviral cocktails or an academic conspiracy to bring in tons of grant money (or both)–and is ruthlessly enforced, crushing any who would “question it,” such as Peter Duesberg. Some HIV/AIDS denialists have even likened the establishment a “criminal enterprise” in “crushing dissent.” Indeed, antivaccinationists use similar rhetoric labeling vaccines a big pharma conspiracy to make lots of money and routinely argue that science is wrong and anecdotes should trump science, most infamously when Jenny McCarthy exclaimed that her son Evan “is my science.” What is such an argument other than that personal experience telling “Dr.” McCarthy that vaccines caused her son’s autism is a “narrative” that’s just as valid as the “narrative” of the scientific evidence that says they almost certainly did not?

It’s not just medicine, either. Pseudoscientists and antiscientists such as creationists invoke variations of postmodernist criticism too. In all fairness, I have been told by some who have studied postmodernism that these invocations are almost always bad postmodernism, but they are used nonetheless. Generalizing further, it’s not even just medicine or science; it can be history too. Think Holocaust deniers, JFK assassination conspiracy theorists, or even 9/11 Truthers. On favorite variant of this gambit is to label science as “dogma” or “religion,” particularly a “fundamentalist” religion. Of course, one key difference between science and fundamentalist religion is that science is inherently self-correcting. True, it may take a long time and be a very messy process, particularly in medical science, but eventually in medicine treatments found through science and clinical trials to be ineffective or to have too many side effects for their benefit are discarded. Contrast that to “alternative” medicine, where prescientific ideas about how the body works (vitalism, for instance) and religious ideas (what are reiki and other forms of “energy healing” but a form of faith healing, in which the healer is viewed to have some skill at manipulating “life energy” for therapeutic effect?) withstand all evidence showing them to have no basis in science or efficacy above that of an elaborate placebo. Of course, that’s why postmodernism is so attractive to CAM aficionados. If these prescientific ideas are just another narrative with no objective means of showing it to be a less valid description of reality than medical science, there is no reason to prefer science over such woo. In such a relativistic worldview, then it’s easy to make the appeal to us “rigid” and “close-minded” scientists to be “open-minded” to the point that our brains fall out.

For CAM practitioners and all advocates of pseudoscience and antiscience, whether they realize it or not, postmodernist assaults on the very basis of science are the gift that keeps on giving. After all, to the CAM advocate, it’s all about changing the rules of evidence when analysis under the current rules show your favored therapy to be nonsense.